Melanie Cole, MS (Host): Welcome to Bryan Health Podcast. I'm Melanie Cole. And today, we're talking about GLP-1s for people living with type 2 diabetes. Joining me is Dr. Madeline Jones-Ryan, she's an endocrinologist at Bryan Health. Dr. Jones-Ryan, thank you so much for joining us today. What are GLP-1s? We're hearing more and more about these. Tell us a little bit about how they work, how they're given. Give us a little explanation of them.

Dr. Madeline Jones-Ryan: So, GLP-1s are a newer type of medications that were originally designed for type 2 diabetes, and they have lots of different functions. One is to increase insulin that the pancreas releases when patients are to eat. Another is to block glucagon production, which can increase blood glucoses.

Another is to slow stomach emptying, and they also work on a certain part of the brain to help people feel full quicker. There's also a GLP, GIP medication that has come out, and this affects how fat is deposited in the body.

Melanie Cole, MS: So interesting. So, tell us a little bit about the pros and the cons of GLP-1s risks and side effects, long-term complications. Tell us about also patient selection for these.

Dr. Madeline Jones-Ryan: There are a lot of pros for these medications, and I'm sure patients feel like doctors are encouraging them to take them all the time. And that's because for diabetics, we're seeing improved blood sugars. We're seeing a 5-10% weight loss with the GLP medications and up to 20% weight loss with the GLP GIP medications. There's also been studies that have shown reduced cardiovascular risks for things like heart attacks and strokes and overall risk reduction for all causes of death in patients who take them. But there are some risks with these medications. And so, lots of patients who take them experience some GI concerns, usually nausea, vomiting, diarrhea, constipation, which are the most common.

Rarely, we can see people have episodes of pancreatitis. People who are on other diabetes medications like insulin can have episodes of low blood sugars or hypoglycemia. A few patients have allergic reactions where the medications are injected. There can be some changes in vision. And people can have loss of vision rarely. And then, a lot of the studies showed a certain type of thyroid cancer called medullary thyroid cancer in rats. This hasn't been well studied in humans, but we tend to avoid these medications in people with a history of a certain condition called MEN. Other people that we avoid these medications with are people who have unexplained pancreatitis. So if they got admitted for pancreatitis, and we don't know why, we would not treat them.

Melanie Cole, MS: Dr. Jones-Ryan, let's talk a little bit about the benefits for people living with type 2 diabetes. You have so many tools in your toolbox these days, and we're learning more and more about sugar control. Tell us how these work for these patients. What have you seen?

Dr. Madeline Jones-Ryan: So, these medications have been a huge benefit to people with type 2 diabetes. We have been able to see a lot of them get off insulin completely with these medications, and a lot of it is they increase the insulin that the pancreas can release. When they're on these medications, they also control some of the hunger, and so patients are not eating as much, meaning they don't need as much insulin.

Melanie Cole, MS: When in the course of their treatment do you recommend this to a patient?

Dr. Madeline Jones-Ryan: Usually, with patients, if I see them and we can't get glucose control with something simple like metformin, I feel that there is so much benefit to this class of medications with the weight loss and the reduction of heart attack and stroke. This is usually a medication I use pretty early on in their treatment.

Melanie Cole, MS: Does it go with other medications like metformin, or do they go off of that once they go on a GLP-1?

Dr. Madeline Jones-Ryan: It depends. Some patients, we continue with the metformin because they need the improved glucose control and they aren't able to just get it with the GLP, and it takes some time to increase these medications up to the max dose. It can take months for patients to get up to a dose where they see benefit. So usually, we start by adding it on to other meds and then you can taper off depending on how they respond.

Melanie Cole, MS: What about if they go off this medication, the GLP-1s, what can they expect if they stop taking them? So if they've achieved good control and you like what's happening, do you then taper them off? Or is this something that they stay on for quite a long time?

Dr. Madeline Jones-Ryan: It depends on the patients. A lot of patients who went on it, and then they did huge lifestyle modifications, so they greatly adjusted their diet, they started being more physically active and they have seen significant weight loss, they can taper off of it. But patients usually tell me if we decrease the dose or they couldn't get it, then we're seeing increased hunger and it's usually worse than it was before they started the medication. So, a lot of patients when they're on these meds, they say, "Oh, I am never hungry. I don't have all the food noise." And once we stop it, all of that comes back. And so, usually, we get patients up to a max dose and sometimes we can taper down to a lower dose, but a lot of patients have not been successful at completely stopping it.

Melanie Cole, MS: Is there a generic version?

Dr. Madeline Jones-Ryan: So for a while, there was a shortage of the medications and there were compounding pharmacies that were creating generic semaglutide or tirzepatide, but these were not truly generics. And so, these medications have only been out a few years, so there is no generic of Wegovy, Ozempic, tirzepatide, which is also Mounjaro or Zepbound. They're getting into more generics for things like Victoza, but that's a once daily injection versus the once a week injections.

Melanie Cole, MS: Tell us a little bit about some of the things that patients can do, because you mentioned that they can taper down a little if lifestyle and behavior modifications really start to help their type 2 diabetes. When you're speaking with them, counseling them, working with them every day, what is it you tell them? What do you want them to be doing along with these adjuvant therapies, these medication interventions that they're doing? What do you want them to know?

Dr. Madeline Jones-Ryan: So with these medications, we have started to see patients lose a lot of body fat and muscle strength. And so, to kind of counteract the loss of the muscle strength, we're encouraging these relatively high protein diets anywhere from 90 to 100 grams a day with additional strength training, you know, 15 to 30 minutes, at least two days a week, and then that routine cardio. And I tell patients, I'm like, "You don't have to run a marathon, but I want you to get up and move and get your heart rate up," because that's how we see these medications work best as if people are able to burn the calories and suppress their hunger.

Melanie Cole, MS: There's been a lot of talk in the media about these medications. As you said, there was a bit of a shortage for a little while. And I'd like you to speak just for a minute about people that take these medications that don't have type 2 diabetes.

Dr. Madeline Jones-Ryan: So, the medications for weight loss have been semaglutide and tirzepatide and liraglutide or Saxenda, have all been approved for just obesity. And there has been a lot of people that kind of feel that this is their trick to be able to lose weight if they've never been able to lose weight. But I usually recommend that it gets dosed in a medical setting where someone is encouraging you to make the lifestyle changes, we tend to see people that use it short term and then fall off, they have the weight regain because they haven't focused on making the lifestyle changes.

Melanie Cole, MS: And that's such an important point that you just made, Dr. Jones-Ryan, because as we link obesity and diabetes together, we know that these are risk factors and that they can also contribute to other diseases and chronic conditions, heart disease and issues. So, I'd like you to wrap this up for us with your best advice about GLP-1s, obesity, type 2 diabetes, lifestyle. It's a lot to ask, but I'd like you to really wrap it up with your best advice about why it's so important that they meet with their provider and go over all of these options and the tools in your toolbox to help us all get healthier.

Dr. Madeline Jones-Ryan: When we look at society today, there's a lot of people that have become obese and, you know, we could spend hours talking about why, but we look at the risks of then developing type 2 diabetes. And when we're looking at treatment, the goal is to change how we got to that point. And so, it becomes, A, we can use medications as a tool, but it's only a tool. It's not going to completely cure the disease. And so, I think the big thing to focus on is using medications. So, you have to see your doctor to get your medications. You also could benefit from meeting with a dietician who can help looking at what food changes you can make, and then looking at meeting with an exercise physiologist to review how to add in all of that physical activity that we encourage. It becomes a whole team-based approach to treating this very complex disease.

Melanie Cole, MS: It certainly is a multidisciplinary approach, but very comprehensive and can help so many people. Thank you so much, Dr. Jones-Ryan, for joining us today. And I'd like to thank our Bryan Foundation partner, Medical Solutions. To listen to more podcasts from our experts, you can always visit bryanhealth.org/podcasts.

That concludes this episode of Bryan Health Podcast. Please always remember to subscribe, rate and review Bryan Health podcast on Apple Podcast, Spotify, iHeart and Pandora. Until next time, I'm Melanie Cole.